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Home My WebLink AboutWiring Permit - Permits #12605-01 - 70 KINGSTON STREET 8/19/2015 i 1 r Date . NOArh TOWN OF NORTH ANDOVER o * s r PERMIT FOR WIRING CH This certifies that r 8 has permission to perform ..... f.. ' F .. .. ....a:.. :. :....................... r wiring in the building of !L io o t ................... ......... at ..............6�.... t'. " ,North Andover,Ma ss. )� F Fee,�.. ,._) . ...........LIc. No. �a a� H. 7 G ELECTRICAL INSPECTOR Check# =� y //�� DD// // Official Use Only lommonweaGEh o��aAdachu�ei� Of 2etoartmetil ol5ire Servicee Permit No. Occupancy and Pee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank)' APPUCAT6QN FOR PERWT TO PERFORM ELEC MCAL WORK All work to be,performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12,00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 92 1 041 ! __ City or Town of: &1„ I-(e f To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street&Number) Oy ner'or Tenant e e� Telephone No. O,?mer's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building p s ILAyiAt\,'m L Utility Authorization o. — Existing Service Amps J g' / ,Yolts Overhead ❑ Undgrd No.of Meters New Service _ Amps Je, /CLQ0VoltS Overhead ❑ Undgrd No, of Meters Number of Feeders and Ampacity Location a d Nature of Proposed Elec i al Work, J qL s aj Completion of the followin table m be waived b�the his ector of Wires. No. of Recessed Luminaires No. of Ceit.-Susp. (Paddle)Fans No, of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA Above ❑ In- No, of Luminaires Swimming Pool ❑ o. o +mergency ig tmg . rnd. rnd. Bat' Units No. of Receptacle Outlets No, of Oil Burners FIRE ALARMS No,of Zones No, of Switches No.of Gas Burners No. of Detection and Initiating Devices No, of Ranges No.. of Air Cond, Total Tons No. of Alerting Devices No. of Waste Disposers. Heat Pump 1\',umber Tons KW No. of Self-Contained Totals: Detection/Alerting Devices No, of Dishwashers Space/Area Heating KW Local❑ Municipal El Other Connection No. of Dryers Heating Appliances KW SecNo of Detvile s:or E uivalent No..of Water KW No, of No. of Data Wiring: Heaters . Signs Ballasts No.of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring; No.of Devices or Equivalent E OTHER: g Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value o Electrical Work: 11O o r (When required by municipal policy.) Work to Start: q Inspections to be.requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waivedaby the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent, The undersigned certifies that such cov age is in force,and hps exhibited proof of same to the permit issuing office., CHECK'ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certol, under th/e�pains and penalties ofpe[Hwy that the information.on this application is true and complete. FIRM NAME;^t �°l Ct f 1 1 ` LIC, NO.: A (� Licensee: "` ' Signature Z LIC.NO.:r aOa (If applicable enter "exempt"in thA ense number line, l Bus.Teh No.: ('1 � Address: / Q�t ta} �r�r e 1 V1%)t'!�r A` Alt,Tel,No.: - 44 *Per M,G.L, c. 147, s. 57-61,security work requires Department of Public Safety"S"License: Lic,No, OWNER'S INSURANCE WAIVER. I am aware that the Licensee does not have the liability insurance coverage normally required by law, By my signature below, I hereby waive this requirement, I am the(check one) ❑ owner ❑owner's agent. OwnSiang uAgent r PERMIT FEE,, $ Signature Telephone No. 1 V V The Commonwealth of Massachusetts . Department oflndustrialAceldents 1 Congress Sheet;Suite 100 Boston,MA 02114-2017 .` www.mass.gov/dia yJ'V Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Piumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Please Print Le gib Applicant Information S l Name(Business/organization/lndividual): Q `� �� `C� Address: t AM-e v City/State/Zip: $hone#: y 3 Gc' Arey an employer?Checktha appropriat box: Type of project(Vequired): 1.�J l aam a employer with •0 _employees(full and/or part-time).* 7. ❑New constiuction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9• ❑Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp,insurance required.]t 10 0 Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11. lectrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 14 Other 6.0 We are a corporation and its officers have exercised their right of'exemption per MGL c. 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information, t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,ttiey must provide their workers'comp.policy number. I am an employer drat is providing workers'compensation insurance for my employees.'Below is the policy and job site information. ej4, W t��a! 5��i n� - etc Insurance Company Name:t 0,A A Al x xns y e e C ---pX-A�Q Policy#or Self-ins.Lic.#:1 ) _3 0 p4 0 " 00 14�( -Q Expiration Date: `�1 sa�?� e Job Site Address: '\M - City/State/Zip: Not, e� , 0 194, Attach a copy of the workers' ompensatio policy declaration page showing the policy number and expirati a date). Failure to secure coverage as required under MGL e. 152,§25A is a criminal violation punishable by a fine up to$1;500.00 and/or one-year hnprisonment,as well as civil penalties in the form of a STOP WORD ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be.fbrwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify tinder the ains andpenalties ofperjury that the information provided above is true and correct. Sip-nature: Phone# Official use only. Do not tvrite in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk. 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: r ✓ R+:ti}1��s��Gi�`'Ek� �^ 2C i, Zer�E ��1,14/1�� 4 6 JCS ,. sootfi�ta�ea nuz?eo z�q6� .�,q r